Provider Demographics
NPI:1073568671
Name:SUNRISE MANOR NURSING HOME, INC.
Entity Type:Organization
Organization Name:SUNRISE MANOR NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-607-7595
Mailing Address - Street 1:1325 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5704
Mailing Address - Country:US
Mailing Address - Phone:631-665-4960
Mailing Address - Fax:631-665-9411
Practice Address - Street 1:1325 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5704
Practice Address - Country:US
Practice Address - Phone:631-665-4960
Practice Address - Fax:631-665-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5154321N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308521Medicaid
NY00308521Medicaid
NY1130210001Medicare NSC